Classifications

• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/56—Compounds containing cyclopenta[a]hydrophenanthrene ring systems; Derivatives thereof, e.g. steroids
  • A61K31/57—Compounds containing cyclopenta[a]hydrophenanthrene ring systems; Derivatives thereof, e.g. steroids substituted in position 17 beta by a chain of two carbon atoms, e.g. pregnane or progesterone
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P9/00—Drugs for disorders of the cardiovascular system
  • A61P9/10—Drugs for disorders of the cardiovascular system for treating ischaemic or atherosclerotic diseases, e.g. antianginal drugs, coronary vasodilators, drugs for myocardial infarction, retinopathy, cerebrovascula insufficiency, renal arteriosclerosis

Definitions

• This invention relates to the administration of progesterone for the purpose of treating or reducing ischemia or incidence of cardiovascular events.
• Ischemia is a decrease in the blood supply to a body organ, tissue or part caused by constriction or obstruction of the blood vessels. Ischemia is often linked to coronary artery disease, cardiovascular events, angina, headaches or other vascular symptoms.
• Estradiol 17 ⁇ (E2) has anti-ischemic properties and has been suggested for primary and secondary prevention of coronary artery disease in menopausal females.
• progestins which include progesterone and the synthetic progestins, in order to reduce the occurrence of uterine malignancy.
• the synthetic progestins unlike progesterone, normally can be effectively administered orally, and so have been the predominant choice over progesterone itself, which is minimally active when administered orally.
• progestins such as medroxyprogesterone acetate (MPA)
• MPA medroxyprogesterone acetate
• Use of progestins in women with cardiovascular problems has often been avoided due to negative effects associated with these drugs.
• MPA is one of the most prescribed and tested progestins in hormone replacement therapy.
• Use of a progestin in hormone replacement therapy that actually supplements, rather than adversely interferes with, estrogen replacement therapy for women with ischemia is therefore of particular interest.
• administration of progesterone itself provides this unexpected benefit.
• Estrogen replacement therapy (ERT) in post-menopausal women inhibits the development of atherosclerosis and reduces the frequency of cardiovascular events. At the same time, though, prolonged, unopposed ERT has the potential to also cause hyperplastic and perhaps carcinomatous effects. Progestins have long been used to protect the endometrium from these deleterious effects of ERT. However, synthetic progestins are well known to act as vasoconstrictive agents to reduce the cardioprotective effects of estrogen replacement therapy on post-menopausal women. This is a main concern about progestin administration. See, e.g.. Sarrel, P. M., Menopause: The Journal of the North American Menopause Society.
• MPA was shown to diminish the beneficial effect of conjugated equine estrogens on vasomotion of diet-induced atherosclerotic coronary arteries in monkeys. Williams, J. K., et al.. Journal of the American College of Cardiology. 24(7): 1757-61 (1994).
• the present invention comprises the administration of progesterone to treat or reduce ischemia or incidence of cardiovascular events, or to treat coronary artery disease.
• progesterone is demonstrated to reduce ischemia.
• progesterone but not the synthetic progestins, can be used in hormone replacement therapy with positive effects, rather than negative effects, on ischemia treatment.
• progesterone as taught by the instant invention is particularly useful, for example, with patients undergoing estrogen replacement therapy.
• Estrogen replacement therapy for menopausal patients with coronary artery disease is often accompanied by adjunctive administration of progestins, to counter any estrogen-induced tendency to promote uterine malignancy.
• synthetic progestins which are normally effective when administered orally (unlike progesterone), tend to at least partially reverse the beneficial results demonstrated by chronic estrogen therapy on myocardial ischemia. Accordingly, the use of progestins in women with cardiovascular problems has often been avoided.
• Progesterone has now been demonstrated to maintain or reduce, rather than to increase, ischemia.
• progesterone is demonstrated to further reduce myocardial ischemia.
• One specific example detailed below reports a recent study which administered progesterone to menopausal women undergoing estrogen therapy for treatment of effort- induced myocardial ischemia. The progesterone reduced ischemia above and beyond the treatment benefits achieved with estrogen alone.
• the mode of administration can easily be varied to achieve positive results in a far broader spectrum.
• the mode of administration or the subject population should be expected to affect the ultimate efficacy of progesterone used to treat or reduce ischemia.
• Various routes of administration, as well as specific dosing can be routinely evaluated through traditional dose ranging studies to easily identify appropriate dosing regimens for specific patients or population.
• the specific drug delivery formulation chosen and used in the Example below comprises a cross-linked polycarboxylic acid polymer formulation, generally described in the U.S. Patent No. 4,615,697 to Robinson (hereinafter “the '697 patent”), which is incorporated herein by reference.
• Such a formulation could be prepared with progesterone, for administration to mucosal surfaces, particularly in a body cavity, as further described in the U.S. Patent No. 5,543,150 to Bologna and Levine (hereinafter “the '150 patent”), which is incorporated herein by reference.
• At least about eighty percent of the monomers of the polymer in such a formulation should contain at least one carboxyl functionality.
• the cross-linking agent should be present at such an amount as to provide enough bioadhesion to allow the system to remain attached to the target epithelial surfaces for a sufficient time to allow the desired dosing to take place.
• the formulation remains attached to the epithelial surfaces for a period of at least about twenty- four to forty-eight hours.
• results may be measured clinically over various periods of time, by testing samples of the vaginal vault for pH reduction due to the continued presence of the polymer.
• This level of bioadhesion is usually attained when the cross- linking agent is present at about 0.1 to 6.0 weight percent of the polymer, with about 1.0 to 2.0 weight percent being preferred, as long as the appropriate level of bioadhesion results.
• Bioadhesion can also be measured by commercially available surface tensiometers utilized to measure adhesive strength.
• the polymer formulation can be adjusted to control the release rate of the progesterone, e ⁇ ., by varying the amount of cross-linking agent in the polymer.
• Suitable cross-linking agents include divinyl glycol, divinylbenzene, N,N- diallylacrylamide, 3,4-dihydroxy-l,5-hexadiene, 2,5-dimethyl-l,5-hexadiene and similar agents.
• a preferred polymer for use in such a formulation is Polycarbophil, U.S. P., which is commercially available from B.F. Goodrich Speciality Polymers of Cleveland, OH under the trade name NOVEON®-AAl .
• bioadhesive polymers that may be used in such a drug delivery system formulation are mentioned in the '697 patent.
• these include polyacrylic acid polymers cross-linked with, for example, 3,4-dihydroxy-l,5-hexadiene, and polymethacrylic acid polymers cross-linked with, for example, divinyl benzene.
• bioadhesive polymers typically, these polymers would not be used in their salt form, because this would decrease their bioadhesive capability.
• bioadhesive polymers may be prepared by conventional free radical polymerization techniques utilizing initiators such as benzoyl peroxide, azobisisobutyronitrile, and the like. Exemplary preparations of useful bioadhesives are provided in the '697 patent.
• additives taught in the '697 patent may be mixed in with the cross- linked polymer in the formulation for maximum or desired efficacy of the delivery system or for the comfort of the patient.
• additives include, for example, lubricants, plasticizing agents, preservatives, gel formers, binders, vehicles, coloring agents, taste and/or odor controlling agents, humectants, viscosity controlling agents, pH-adjusting agents and similar agents.
• COL- 1620 the specific preparation used in the study discussed in the Example below, consisted of the following:
• Sorbic acid is a preservative, which may be substituted by any other approved preservative, such as benzoic acid or propionic acid.
• Carbomer 934P is a gel former, which may be substituted by other gel formers including, but not limited to, Carbomer 974, Carbomer 980, methyl cellulose or propyl cellulose.
• Glycerin is a humectant; alternative humectants include, for example, propylene glycol or dipropylene glycol.
• Mineral oil and hydrogenated palm oil glyceride are lubricating agents; alternatives include, for example, any mineral oil or vegetable oil, such as canola oil, palm oil or light mineral oil.
• Preparation of the formulation involves hydration of the polymers, separate mixing of water-soluble ingredients (the “polymer phase”) and oil-soluble ingredients (the “oil phase”), heating and mixing of the two phases, and homogenization of the mixture. All ingredients in COL- 1620 are well known and readily available from suppliers known in the industry.
• the polymer phase may generally be prepared by dissolving the sorbic acid in purified water (along with an excess volume of about 3% of the intended volume of water, to account for evaporation losses), preferably at 75-78 °C.
• the solution is cooled, generally to room temperature, and the polycarbophil and Carbomer 934P are added.
• the polymers are hydrated by mixing for several hours, generally about 2-3 hours until a uniform, smooth, lump-free gel-like polymer mixture is obtained. When the polymers are completely hydrated, the progesterone is added and mixed in, until a homogeneous suspension is obtained.
• the oil phase is generally prepared by melting together the hydrogenated palm oil glyceride, glycerin and mineral oil. The mixture is cooled to about 60 °C, while the polymer phase is warmed to about the same temperature. The oil phase is then added to the polymer phase, and the two phases are mixed thoroughly, producing a uniform, creamy white product with a pH generally of about 3. When the mixture has cooled, it is de-aerated. The resulting product is aseptic, because of the nature of the preparation as well as the pH and the presence of preservatives.
• the composition of the formulation can be varied to affect certain properties of the formulation.
• concentration of the bioadhesive polymer can be adjusted to provide greater or lesser bioadhesion.
• the viscosity of the gel can be varied by varying the pH or by changing the concentration of the polymer or gel former.
• concentration of the oils compared to the water can be varied to modulate the release rate of the progesterone from the drug delivery system.
• the pH can also be varied as appropriate or to affect the release rate or bioadhesiveness of the formulation.
• a 12-lead electrocardiogram was obtained at rest, every minute during the exercise test, at the onset of 1 mm of ST segment depression, at peak exercise and every minute during recovery.
• Leads V2, V5 and II were continuously monitored and a complete 12- lead electrocardiogram obtained at the end of each stage, at the onset of 1 mm planar ST segment depression and at peak exercise.
• Systolic and diastolic blood pressure were measured at rest and monitored every 3 minutes during exercise and recovery.
• a positive response in the EKG was defined in the study protocol as a horizontal or downsloping ST segment depression of at least 1 mm at 60 ms after the J point occurring at least in 6 consecutive complexes. Otherwise, the patient was determined to have a "negative response" in that leg of the testing.
• the exercise test was concluded at the point of physical exhaustion, ST segment depression greater than 3 mm, severe angina, severe dyspnoea, complex arrhythmia or a decline in systolic blood pressure greater than 20 mm Hg.
• Total exercise time, time to myocardial ischemia, duration of EKG ischemic changes, heart rate, blood pressure at the onset of 1 mm ST segment depression, maximal ST depression and the time of development of angina during exercise was recorded.
• the ST segment, 60 ms after the J point was evaluated after signal averaging using a computer-assisted system in all 12 leads. The lead showing the greatest STsegment depression in the pre-treatment exercise test was selected for analysis.
• (+) lengthening of time (no quantity: current test was negative)
• (+) lengthening of time (no quantity: current test was negative)
• the mean time to ST depression for E2 alone before E2 + P was 348 seconds.
• the mean time to ST depression for E2 + P was 416 seconds. This difference was statistically significant, with a p value of 0.03.
• 12 of the test subjects demonstrated an improvement when E2 + P was administered, as compared with E2.
• Each of the other four subjects demonstrated no quantifiable change, each having negative tests for both the E2 + P and the prior E2 intervals of the study.
• the E2 + MPA administration resulted in eleven subjects exhibiting worse results compared to E2. Only four of the E2 + MPA subjects exhibited an improvement; one subject demonstrated no change.

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• 1996
  • 1996-11-04 US US08/743,153 patent/US5985861A/en not_active Expired - Lifetime
• 1997
  • 1997-11-03 ZA ZA9709862A patent/ZA979862B/xx unknown
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  • 1997-11-04 BR BR9710918-5A patent/BR9710918A/pt not_active Application Discontinuation
  • 1997-11-04 ES ES97946681T patent/ES2262196T3/es not_active Expired - Lifetime
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• 1999
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